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LPRC Swim Team

Family Registration 2004

 

Child’s Name

(Last Name, First Name)

Age

Date of Birth

Paid

Please list any dates child will be out of town

(or can’t attend swim meets)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The cost for joining the swim and/or dive team is $50 per child, with a maximum of $130 per family.

Address___________________________________________________________________

 

Mother

Father

Other Relative

(if a volunteer)

Name

 

 

 

Daytime Phone

 

 

 

Evening phone

 

 

 

E-mail

 

 

 

Volunteering to help Swim Team as:

Please check

Please check

Please check

Referee

 

 

 

Starter

 

 

 

Stroke & Turn Judge

 

 

 

Relay Take-off Judge

 

 

 

Chief Timer

 

 

 

Timer

 

 

 

Head Table Worker

 

 

 

Table Worker

 

 

 

Announcer

 

 

 

Clerk of Course

 

 

 

Data Entry Clerk

 

 

 

Snack Bar Helper

 

 

 

50-50 Raffle Seller

 

 

 

Marshall

 

 

 

Meet set-up helper

 

 

 

Social events coordinator

 

 

 

Trophies and awards coordinator

 

 

 

Swim cap and t-shirt sales person

 

 

 

Equipment manager

 

 

 

 

LPRC Junior Tennis

                                                                     2004 Registration                      

 

 

 

Child’s Name

 

 

Child’s Name

Child’s Name

 

Birth Date

Birth Date

Birth Date

 

                                                                     Weeks                                                                                                 Total

Tennis Team

$25 per child, maximum $65 per family

6/7-7/28

Child’s Name

Child’s Name

Child’s Name

 

$_____

Tennis Lessons

Pay by the Week - $20 per week for 4 lessons ($10 for 2 lessons weeks of June 7 and June 14 and $15 for week of 7/5)

 

Special Fee Schedule for Multiple Summer Sessions!

Sign up for all 8 weeks for  $125

If paid by May 25

6/7  ($10)

 

 

 

$_____

6/14 ($10)

 

 

 

$_____

6/21 ($20)

 

 

 

$_____

6/28 ($20)

 

 

 

$_____

7/5 ($15)

 

 

 

$_____

7/12 ($20)

 

 

 

$_____

7/19 ($20)

 

 

 

$______

7/26 ($20)

 

 

 

$_____

           

GRAND TOTAL  $____________

 

Mother

Father

Other Relative

(if a volunteer)

Name

 

 

 

Daytime Phone

 

 

 

Evening phone

 

 

 

E-mail

 

 

 

Volunteering to help Tennis Team by:

Please check

Please check

Please check

Providing refreshments for home games

 

 

 

Driving players to away games

 

 

 

Trophies and awards coordinator

 

 

 

 


Lincolnia Park Recreational Club, Inc. (LPRC)

 

PARENTAL CONSENT AND MEDICAL RELEASE FORM

 

ACKNOWLEDGEMENT OF RISK AND INSURANCE STATEMENT

(To be completed and signed by parent/guardian)

I give permission for (name of child): __________________________________ to participate in any of the following sports (circle all that apply):   SWIMMING,  DIVING LESSONS,   TENNIS   He/she is insured by our family policy with:

Name of Insurance Company:____________________________________________________

Policy Number _____________________   Name of Policy Holder______________________

I will not hold LPRC responsible in case of accident or injury as a result of these activities. I further release LPRC

from responsibility from any injury sustained by my child while he/she is a participating member of said program.

 

EMERGENCY PERMISSION FORM

 

Child’s Name _______________________________Age_____ Date of Birth______  Sex _____

Name of parent or guardian________________________________ Phone # (____)___________

Home address __________________________________________________________________

Name of personal physician______________________________    Telephone (____)__________

Preferred Hospital(s) _____________________________________________________________

Please list any significant health problems that might be important to a physician evaluating your child in case of an emergency    _____________________________________________________

______________________________________________________________________________

Please list any allergies to medications, etc. ______________________________________________________________________________

Has child been prescribed an inhaler or Epi-pen? ____

Is child presently taking medication?____  If so, what type?_______________________________

Does child wear contact lenses? ______ Please list date of last tetanus shot  __________________

 

EMERGENCY AUTHORIZATION: In the event I cannot be reached in an emergency, I hereby give permission to physicians selected by the coaches and staff of Lincolnia Park Recreational Club to hospitalize, secure proper treatment for and to order injection and/or anesthesia and/or surgery for the person named above.

Daytime phone number (where to reach you in emergency) (____)________________________

Evening time phone number (where to reach you in emergency) (         )____________________

Signature of parent or guardian____________________________       Date_______________

Relationship to child_______________________________

Emergency Permission Form may be reproduced to travel with respective teams and is acceptable for emergency treatment if needed.